Nonparticipating providers have not agreed to accept Blue Cross and Blue Shield of Minnesota’s allowed amount as payment in full.
The allowed amount calculated for a nonparticipating provider for most services is usually less than the allowed amount for a participating provider for the same service and can be significantly less than the nonparticipating provider’s billed charges. It can be significantly less than the nonparticipating provider’s billed charges. The nonparticipating provider can bill you for the difference between the allowed amount and billed charges. When you use a provider that does not contract with a Blue Cross and Blue Shield plan* (a nonparticipating provider), benefits are substantially reduced and you will likely incur significantly higher out-of-pocket expenses.
Blue Cross and Blue Shield of Minnesota contracts with a large majority of doctors, hospitals and clinics in Minnesota to be part of its network. Other Blue Cross or Blue Shield plans contract with providers in their states as well. These health care providers are referred to as “participating providers.” They have agreed to accept as full payment (less deductibles, coinsurance and copayments) an agreed upon amount, the “allowed amount,” that a Blue Cross or Blue Shield plan has negotiated with its participating providers.
A nonparticipating provider does not have any agreement with a Blue Cross or Blue Shield plan and is free to bill any amount the provider chooses. This billed amount will likely be higher than what the Blue Cross or Blue Shield plan has adopted as the allowed amount for nonparticipating providers. In addition, the allowed amount for nonparticipating providers is usually substantially less than the allowed amount for participating providers. In determining the allowed amount for nonparticipating providers, Blue Cross and Blue Shield of Minnesota makes no representations that this amount is a usual, customary or reasonable charge from a provider. You are responsible for paying the difference between the Blue Cross allowed amount and the nonparticipating provider’s billed charges. This amount can be significant and the amount you pay does not apply toward any out-of-pocket maximum contained in the plan.
Cost-sharing amounts that you are responsible for when you see a nonparticipating provider are usually higher than for participating providers.
Although each plan varies, most provide some coverage for nonparticipating provider services. Most plans also have higher co-insurance and other copayments for care received from providers. You are responsible for these amounts in addition to the difference between the nonparticipating provider’s billed charge and the plan’s allowed amount.
Example of payment for nonparticipating provider
The following table illustrates the different out-of-pocket costs a member may incur using nonparticipating versus participating providers for a particular service. The example presumes that the member deductible has been satisfied and that the plan covers 80 percent of the allowed amount for participating providers and 60 percent of the allowed amount for nonparticipating providers. It also presumes that the allowed amount for a nonparticipating provider will be less than for a participating provider. The difference in the allowed amount between a participating and nonparticipating provider could be more or less than the 40 percent difference in the example below.
What is Blue Cross and Blue Shield of Minnesota’s allowed amount for nonparticipating providers?***
For physicians, clinics or Ambulatory Surgery Centers (ASC) services by nonparticipating providers in Minnesota, with some exceptions, the allowed amount is most commonly the amount in the Nonparticipating Provider Professional Services in Minnesota Fee Schedule.****
» Provider professional services sample fee schedule (PDF)
» Chiropractic provider sample fee schedule (PDF)
» Ambulatory Surgery Center (ASC) fee schedule (PDF)
You may need to talk with your nonparticipating provider to determine what procedure codes are applicable to the services your nonparticipating provider will provide in order to determine what benefits are available. The allowed amount is the lesser of (1) the Nonparticipating Provider Professional Services in Minnesota Fee Schedule, or (2) 90 percent of the nonparticipating provider’s billed charges. The determination of the allowed amount is subject to all Blue Cross business rules as defined in the Blue Cross Provider Policy and Procedure Manual (PDF). As a result, Blue Cross could bundle services, take multiple procedure discounts and/or other reductions as a result of the procedures performed and billed on the claim. No fee schedule amounts include any applicable tax.
Payments using these fee schedules are subject to all member contract provisions (including deductibles, copayments, limitations and exclusions). A procedure listed on a fee schedule does not guarantee payment. The fee schedule that is current as of the time the services are provided will be the fee schedule that is used for determining the allowed amount.
The allowed amount for all other nonparticipating providers (facility services) in Minnesota***
The Blue Cross and Blue Shield of Minnesota allowed amount for nonparticipating provider facility services is 40 percent of the facility’s billed charges, subject to business rules established in the Blue Cross Provider Policy and Procedure Manual (PDF). Examples of facility-based provider types include, but are not limited to hospitals, skilled nursing facilities or renal dialysis centers. As a result, certain procedures billed by a nonparticipating provider facility may be combined into a single procedure or denied as not a covered service for purposes of determining what the 40 percent will be applied against.
The allowed amount for nonparticipating provider professional services (physicians or clinics) outside Minnesota***
For nonparticipating provider physician or clinic services outside of Minnesota, with certain exceptions, the allowed amount is determined by the local Blue Cross and/or Blue Shield Plan, unless that amount is greater than the nonparticipating provider’s billed charge, or no allowed amount is provided by the local Blue plan. In that case, the allowed amount will be based on a percentage of pricing obtained from a nationwide provider reimbursement database that considers various factors, including the ZIP code of the place of service and the type of service provided. If this database pricing is not available for the service provided, Blue Cross and Blue Shield of Minnesota will use the allowed amount for nonparticipating providers in Minnesota.
The allowed amount for all other nonparticipating providers (facility services) outside Minnesota***
For nonparticipating provider facility services outside of Minnesota, with certain exceptions, the allowed amount is determined by the local Blue Cross or Blue Shield Plan, unless that amount is greater than the nonparticipating provider’s billed charge, or no amount is provided by the local Blue plan. In that case, the allowed amount is determined from a Medicare-based fee schedule. If such pricing is unavailable, payment will be based on a percentage of the nonparticipating provider’s billed charges.
If you have questions about the benefits available for services to be provided by a nonparticipating provider, you will need to speak with your provider and you may call Blue Cross and Blue Shield of Minnesota customer service at the phone number on the back of your member ID card for more information.
*Each Blue Cross or Blue Shield plan is an independent licensee of the Blue Cross and Blue Shield Association.
**Blue Cross will in most cases pay the benefits for any covered health care services received from a non-participating provider directly to the member based on the allowed amounts described here and subject to the other applicable limitations in the plan. An assignment of benefits from a member to a nonparticipating provider generally will not be recognized. This figure, therefore, represents the net cost to the member after being reimbursed by Blue Cross.
***The above summaries for determining allowed amounts are not followed in all cases. Allowances for nonparticipating providers may be greater for emergency services and under special circumstances depending on your contract. Prescription drug payments for nonparticipating pharmacies utilize a different allowed amount. In addition, certain plan sponsors for their group coverage simply defer to the nationwide provider reimbursement database for determining allowed amounts for services provided by nonparticipating providers to their members.
****These proprietary fee schedules are for the information of Blue Cross and Blue Shield of Minnesota members only and are not to be used for any other purpose. They are subject to change without notice.
